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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORICER'SyCOOMPENSATION INSURANCE ATTEDAVIT
(� permittee>
with a principal place of blisiness/residence at:
— / let.d-e-,o�i" ,/R+. (phone#} l�
(str>City/st 2]ip)
do hereby certify, under the pains and penalties of perJury, that
O I am an employer providing the follollving workers compensation coverage for my
employee; off g this job: xd„J 8 7 ql-0 L-/.p - 200
s
4. 27 .N. A-i,/A.#-/ ir L-1 c-- &v0Y dot cr
(Insu.ranoti Company) (policy Number) (Expiration Date)
M""I am a sole proprieto neral �thefonowing r homeowner (circle one) and have hired
the contractors listed be worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
r.
(Name of Contractor) (Insurance Company/Policy Number) (ExTiration Date)
(Name of Contractor) (Lnsurance Company/Policy Number) (FApiration Date)
(Name of Contractor) (Insumce Company/Policy Number) (Expi1aation Date)
(attach adddioail&Smt ifnoc is to include information pertaining to all ooatn ors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that white bomcouix-n%Vbo employ persom to do m jafC*++acr.corjj�,ruaion or repair wvrk oo a dwelling of
not more than threa units in winch the horn mu re4das or oa the grounds appu�therceo an:oot gcn qtly oocsidacd to be
cmployrrs undo the worker's aourpeusation Act(GL152,ss 1(5)),appLication by a homcoavcr for a licczlsc or Permit may evidence tho
legit etatua of an omployer under the Workcet C.oz� Act.
I understand that i copy of this atatcmmt may ba fora mid to the Dcpa t..d of Dial A-6&"&Offioo of Iusuraoco for tbo
coverage vaificaiioa and that fadum to secure coverago under section 25A of MOL 152 can Icad to the imposition of aimin-+1 P=116a
oanisting of a fine of up to S 1,500.00 and/or impr-isr a of tip to oac year and civil peaaltia in the form of a Stop Work OniG and a
fum of S 100.00 a day againA me—
For dep:rtmrntal uao oaly
Permit Number
p{ Lot r't
Si of Li erIDittee to
SECTION 8,-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor, J Not Applicable ❑
Name of License Holder 41
License Number
Address Expiration Date
Si a re Telephone
9...Re ist "red Home` Y vemen 'Co"n rac r "�'' `' Not Applicable ❑
e,i ot 4� 1-3L477
Com an Name Registration Number
-,2 Z- G A /c/.
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
MW
P.,omOwnerEempti rn'
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor. CMR 780 Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official, on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5'- DESCRIPTION OF PROPOSED WORK(check-aIIL pgjgc le)
New House ❑ Addition ❑ Replacement Windows Alterations) 0 Roofing �J
Or Doors ❑ /
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: .s�M��//i`K1 'r Frf� or it �p P t,&,O ,a-a,p�i d Ai4f,.Ar
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D - Sheet D
6a,`"If.New:.house anda.or."ddditidn to 6ki!tihk housing:Complete the'follawing
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT.O.R`CONTRACTOR APPLIES FOR.BUILDING'PERMIT
1, as Owner of the subject property
hereby authorize fvt w .y 46 /l-.l Z. C C to act on
my behalf, in all matters r lative to w k authorized by this b ilding permit application.
Signature of Owner Date
Aethat as Owom/Authorized Agent
hereb the state ents and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and enalties of perjury.
Print Na e
Y , Lf'- O.3
Signat f.Qwww1Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO _ DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
City of Northampton Sat sourer i '
Building Department G �CuflDr ewa. e..:
212-Main Street Se rfSep r t a
Room 100 Wa erlWs v ii
Northampton, MA 01060 T "SetsofS
APR 0gnp;,4j13-587-1240 Fax 413.587.1272 Plot/Sete Plane
OtherSpecify� - � ._
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
O /
d-7-1 Map Lot' Unit
C`i�'►�
Zone overlay:District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
z-A)S)<- I a CAE\ 7
Name(Prin " 4 Current Mailin re
Telephone
ignature 2.2 Authorized Authorized Agent:
11 ro,
Na e rint) Current Mailing Address: �+
ature Telephone
SECTION_3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
10 LINDEN ST BP-2003-0962
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma�Block: 25C-202 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0962
Project# IS-2003-1550
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KENNETH LYNDS 136677
Lot Size(sg. ft.): 10410.84 Owner: KUCZYNSKI THOMAS R&PAMELA L
Zoning.URC Applicant: KENNETH LYNDS
AT. 10 LINDEN ST
Applicant Address: Phone: Insurance:
P O BOX 448 (413) 584-9282
LEEDSMA01053 ISSUED ON.516103 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP SLATE & INSTALL SHINGLES
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sienature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 5/6/03 0:00:00 2404 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
10 LINDEN ST BP-2003-0962
GIS#: COMMONWEALTH OF MASSACHUSETTS
MW:Block: 25C-202 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Catecorv: BUILDING PERMIT
Permit# BP-2003-0962
Project# ]S-2003-1550
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: KENNETH LYNDS 136677
Lot Size(sq. ft.): 10410.84 Owner: KUCZYNSKI T14OMAS R&PAMELA L
Zoning.URC Applicant. KENNETH LYNDS
AT. 10 LINDEN ST
Applicant Address: Phone: Insurance:
P O BOX 448 (413) 584-9282
LEEDSMA01053 ISSUED ON:516103 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP SLATE & INSTALL SHINGLES
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Gii: Insulation:
Final: Smoke: Final: (51<
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL N OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occu an - si nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 5/6/03 0:00:00 2404 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo